The Commission on Audit has called out the Department of Health for more than P1.88 billion in reimbursement claims that the Philippine Health Insurance Corporation, or PhilHealth, denied and returned to hospitals, or RTH, in 2022 due to non-compliance with the law.
A CoA annual report revealed that the DoH had denied P461,727,357 hospital claims and had P1,415,670,444 worth of RTH cases last year.
The audit cited non-compliance with the requirements and conditions provided for under the revised Implementing Rules and Regulations of the National Health Insurance Act of 2013, or RA 7875, and other related PhilHealth issuances.
State auditors said the violations resulted in hospitals losing income, which "could have been used to augment their operating requirements."
Under Section 38, Article VIII of the law, PhilHealth may deny or reduce the payment of claims when such claims are attended by false or incorrect information. Meanwhile, if the claim is denied, the amount of the claim shall not be recovered from the member under Section 47 of the NHIA.
Over-utilization of services, unnecessary diagnostic and therapeutic procedures and interventions, irrational medication and prescriptions, fraudulent or false information as determined by the appropriate office, and failure to comply without justifiable cause with the pertinent provisions of any issuances of the PhilHealth, among others, were found to be the common causes of RTH and denied claims, the CoA said.
Southern Philippines Medical Center had the most denied and RTH claims from PhilHealth, totaling P191,013,899 and P1,214,610,007, respectively.